Provider Demographics
NPI:1740807163
Name:MIRANDA, STACIE STEWART (LOTR)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:STEWART
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:LA
Mailing Address - Zip Code:70754-1130
Mailing Address - Country:US
Mailing Address - Phone:225-686-7600
Mailing Address - Fax:
Practice Address - Street 1:29849 SOUTH MAGNOLIA ST.
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:LA
Practice Address - Zip Code:70754-1130
Practice Address - Country:US
Practice Address - Phone:225-686-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10890225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist